5 Min 
In Practice
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Problem representation
A 44-year-old woman presents with a six-week history of wrist pain and numbness.
Hypothesis generation
Wrist pain can happen to anyone, whether they are active or sedentary. It can be classified as acute pain caused by a specific sudden injury such as a sprain or fracture, or as subacute or chronic long-term pain, resulting from (for example) repetitive stress, arthritis and nerve entrapment.
In this case you can rule out sudden impact as Victoria has had the symptoms for a number of weeks. The following causes can be eliminated:
- Fracture
- Joint subluxation
- Ligament tears.
As Victoria describes sensory disturbances, conditions that can present with tingling should be considered first.
Likely diagnosis
- Nerve entrapment
- Carpal tunnel syndrome
- Ulnar nerve entrapment
- Ganglion cyst.
Possible diagnosis
- Systemic causes
- Gout
- Osteoarthritis (OA)
- Rheumatoid arthritis (RA)
- Tendinopathy.
Critical diagnosis
- Not applicable.
Continued information gathering
Victoria has reported soreness, aching and tingling sensations in her fingers but you need to know the specific location of these symptoms. For example, carpal tunnel affects the thumb and middle fingers; ulnar entrapment the fourth and fifth fingers; and ganglion cyst location is variable but the top of the wrist is a common site.
Victoria’s pain is felt across the inside of her wrist and she has been getting pins and needles mainly in her right little finger. This seems to align with ulnar entrapment. Regarding the nature and timing of the pain, Victoria reports that it is more discomfort than true pain and seems to be fairly constant. This presentation seems to further support ulnar entrapment.
If the symptoms were caused by carpal tunnel syndrome, then night pain is more prominent.
